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A nurse whose left hand is dominant is preparing to perform a straight catheterization for a client who is paraplegic. Which of the following actions should the nurse take?
- A. Use the left hand to cleanse the urinary meatus.
- B. Use the right hand to insert the catheter.
- C. Stand on the client's right side.
- D. Raise the bed to a comfortable working height.
Correct Answer: D
Rationale: The correct answer is D: Raise the bed to a comfortable working height. This is important to prevent strain on the nurse's back and ensure proper ergonomics during the procedure. Standing on the client's right side (Choice C) does not directly impact the procedure. Using the left hand to cleanse the urinary meatus (Choice A) could be challenging for a left-handed nurse and may not be as efficient. Using the right hand to insert the catheter (Choice B) could also be difficult for a left-handed nurse and may affect dexterity. Therefore, raising the bed to a comfortable working height is the most appropriate action to ensure the nurse's comfort and safety while performing the catheterization.
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A nurse is collecting data about a client's skin turgor. Which of the following actions should the nurse take?
- A. Lightly palpate the skin using the fingertips.
- B. Press the skin over the client's ankle bone.
- C. Observe for nonblanching, pinpoint-size, red or purple spots on the skin of the abdomen.
- D. Grasp a fold of skin on the client's forearm or near the sternum.
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Grasping a fold of skin on the client's forearm or near the sternum is the appropriate method to assess skin turgor. Skin turgor is the skin's ability to return to normal after being pinched. By grasping the skin and observing how quickly it returns to its original state, the nurse can assess the client's hydration status accurately. This method is commonly used and recommended for assessing skin turgor.
Incorrect Choices:
A: Lightly palpating the skin using the fingertips does not provide an accurate assessment of skin turgor.
B: Pressing the skin over the client's ankle bone is not the standard method for assessing skin turgor.
C: Observing for nonblanching, pinpoint-size, red or purple spots on the skin of the abdomen is unrelated to assessing skin turgor and indicates a different condition.
A nurse is rehearsing assertive communication approaches to decline leadership of a nursing department committee. Which of the following statements by the nurse demonstrates assertiveness?
- A. You know this is not the right time for me to do this.
- B. Everyone knows there are others who can chair this committee better than I could.
- C. Can you tell me why you chose me?
- D. I decline the opportunity at this time.
Correct Answer: D
Rationale: Assertive communication is direct and respectful, clearly stating a decision without being passive or aggressive.
A nurse is caring for a client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor? (Select all that apply.)
- A. Shallow respirations
- B. Cardiac dysrhythmias
- C. Flushing
- D. Hyperactive reflexes
- E. Abdominal pain
Correct Answer: A,B,D
Rationale: The correct answer is A, B, and D. In metabolic alkalosis, the blood pH is elevated due to an excess of bicarbonate. Shallow respirations (A) occur as a compensatory mechanism to retain CO2 and decrease pH. Cardiac dysrhythmias (B) can result from electrolyte imbalances associated with alkalosis. Hyperactive reflexes (D) are a sign of neuromuscular irritability due to altered electrolyte levels. Flushing (C) and abdominal pain (E) are not typically associated with metabolic alkalosis. In summary, the nurse should monitor for shallow respirations, cardiac dysrhythmias, and hyperactive reflexes in a client with metabolic alkalosis, as they are indicative of the condition and its complications.
A nurse is caring for a client who had a severe traumatic brain injury 3 weeks ago, remains unconscious, and is unlikely to recover. While bathing the client, the assistive personnel (AP) talks to him about current events. The client's partner asks the nurse why the AP talks to the client. Which of the following responses should the nurse make?
- A. I'm really not sure why the assistant is talking to him. Perhaps you should ask her.
- B. Although your partner is not responding to us, he might still be able to hear.
- C. Don't let that concern you. She talks to all her clients, no matter what.
- D. She is an excellent caregiver. She has many others to care for, but she takes the time to talk to your partner.
Correct Answer: B
Rationale: The correct answer is B: Although your partner is not responding to us, he might still be able to hear. This response is correct because research shows that comatose patients can still hear and process information. Talking to the patient can provide comfort, familiarity, and potentially stimulate brain activity.
Choices A, C, and D are incorrect because they do not address the potential benefit of talking to the unconscious patient. A deflects the question, C generalizes the behavior, and D praises the caregiver without explaining the rationale behind talking to the patient.
In summary, choice B is the best response as it acknowledges the potential for the unconscious patient to hear and emphasizes the importance of continuing communication for the patient's well-being.
A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?
- A. Count the apical pulsations for a full minute.
- B. Check the apical pulse with a Doppler device.
- C. Use the diaphragm of the stethoscope to listen to the apical pulsations.
- D. Press the stethoscope firmly against the client's skin.
Correct Answer: A
Rationale: The correct answer is A: Count the apical pulsations for a full minute. This is because counting the apical pulse for a full minute provides the most accurate and reliable measurement of the heart rate, especially in clients taking cardiovascular medications where variations may occur. Checking for a full minute allows the nurse to capture any irregularities or changes in the pulse rhythm.
Choice B is incorrect because using a Doppler device is not necessary for routine assessment of the apical pulse. Choice C is incorrect as the bell of the stethoscope, not the diaphragm, is used to listen to the apical pulse for better sound transmission. Choice D is incorrect as pressing the stethoscope firmly against the skin can distort the sound of the pulse.